“When you’re able to transcend an aversion to silence, you’ll also transcend many other miseries.” ~ Wayne W. Dyer
I’ve been thinking and reading a lot about silence lately. Whether through private meditation or contemplation, or in a social or professional context, silence is an important aspect of our daily experience, and one to which we do not always pay much heed. Silence seems to have become something that we need to actively seek out, by escaping the chaos of everyday life, and intentionally disengaging from email and social media. John Lahr points out that, “accustomed to the veneer of noise, to the shibboleths of promotion, public relations, and market research, society is suspicious of those who value silence”. It is not often a natural part of our everyday experience. Yet we all need silence; it permits creativity and allows restoration and renewal. In the interpersonal context, it reminds us that we can never directly access the lived world of a person other than through representations that we call words. In Quaker practice, silence forms a powerful process for collaborative decision making as well as community formation. Mother Theresa observed that “we need silence to touch souls”.
Consider a person with whom you feel comfortable in silence, perhaps a partner, or close friend. Are there situations in which being silent with that person stops feeling comfortable? If that person is crying, does this make it more or less difficult to stay quiet?
Our feelings and responses to silences in our personal lives are likely to be reflected in how we communicate with our patients, including our levels of comfort and tolerance of silences. With patients, we may find it easier to tolerate silences if we know the person well, if they appear at ease, if they are also able to communicate verbally, and if we have certainty and direction in terms of the plan for their care. We may find ourselves feeling much less comfortable if the person appears distressed, or if we ourselves are struggling with feelings of helplessness or confusion in the face of their situation. In conversations about end-of-life concerns, this silence can take on an additional layer of difficulty, as both the professional and the patient bear witness to numerous existential issues that we may struggle to find a common language for. In the spaces within a conversation, strong emotions can surface, where we experience similar emotions to the person, or where evoke new and difficult emotions within us. These processes in psychoanalytical terms are known as transference and counter-transference, and an awareness of these can enhance our capacity to provide compassionate care.
In facilitating communication skills training with nursing and medical students, students often want to know about “how to manage silence”. Some are aware that silence can be therapeutic, others find them just plain awkward, embarrassing, confusing or challenging, and still others make concerted efforts to avoid silences at all costs. Even though we are taught that over 70% of our communication is non-verbal, we still seem to consider words to be the main vehicle to transmit and receive message.
As health professionals it is natural that we vary in terms of how comfortable we are with silences. And even for one individual, silence may feel natural and comfortable in one setting, yet awkward and painful in another. It seems that tolerance of silences increases in inverse proportion to the perceived futility of the patients’ predicament; in other words, the more easily someone feels the patient can be “helped” (in conventional curative biomedical terms), the more they can rationalize and understand the importance of silence within the encounter.
I remember visiting a young woman at home – a single mother, with three children aged 12 to 18. She was dying from lung cancer. When she told me she had been awake all night worrying about who was going to care for her children after her death and was devastated at the thought of them going into care. She had no contact with their father, and no supportive family nearby. Two of the children were experiencing difficult behavioural issues, partly related to her condition and partly, I think, a result of some tricky social circumstances. I recall feeling actual physical pain and nausea at her words, as well as helplessness and fear (which might well have been fairly similar to the feelings she was describing). Of course, the children had no option other than her worst fear. When she had finished talking about her worries, a gaping silence opened between us – not a comfortable or creative one, but one in which I remember madly fumbling for the right thing to say while trying to suppress the feelings that had arisen in myself. The urge to “do” something tangible was overwhelming – refer her to a Social Worker, prescribe some night sedation, anything to remove this feeling of abject sadness. Alongside these feelings was a darker, more uncomfortable set of responses: “thank goodness my children have two parents”, and “I am lucky not to be in this situation”, both of which I think are fairly natural responses to witnessing suffering, although rarely acknowledged. I think these two responses fairly accurately depict the processes of transference and counter-transference as they may be experienced in such a conversation, and I would imagine that scenarios like this are not unfamiliar for those of use who regularly speak to people at the end of life. Renee Katz and Therese Johnson have edited a remarkable commentary on transference and counter-transference processes in palliative care professionals.
When faced with silences where we do not feel comfortable, we may offer words of support and kindness, or problem-solving solutions of a practical nature. This stems from a well-intended desire to alleviate suffering, as well as potentially being grounded in our own difficult feelings. However, these actions can mean that silences are increasingly avoided, and along with them, opportunities to connect and understand your patient are lost.
A close friend of mine experienced a shattering bereavement a few years ago; her 18-year old son, on a year-out adventure in Colorado, was killed in a serious car accident on a mountain road. A lorry collided with the vehicle in which he and some friends were travelling; several boys died instantly, others were seriously injured, some permanently. she speaks often, and readily (I won’t say easily) about her grief. In the years since his death I feel I have learnt a lot of things about grief of this kind; and a lot of things about silence. In the immediate aftermath of his death, she and her family were inundated with support from the local community, ranging from cooked meals left on the doorstep, to offers of childcare for her remaining two children, to offers of emotional support. She reflects on how these gestures helped her to move dazedly from one day to the next, until the days became weeks, and the weeks drew out into months. Many people found it difficult to speak to her during those awful months. “I just don’t know what to say”, was something I heard a lot. Or, “what do you say to make it better?” Of course, on one level, it is almost impossible to know what to say in such a situation. How can one make sense of a death of this kind? Or offer any kind of wisdom that creates meaning out of loss? The meaning is for the bereaved person to find, in that painful and difficult process known as grief.
There obviously are things which feel “right” to say, just as there are obviously things which are “wrong”. But how often do people offer silence as a means of support in and of itself? And how much is avoiding such silence related to our perceptions of death and dying as a whole?
Avoiding silence gives three clear messages to people who are suffering:
- “I am afraid of what you may say next”
- “I don’t know what to do to help you”
- “I am uncomfortable talking about difficult issues”
In a culture that already finds open conversations about death and dying difficult, this message can potentiate that sense of taboo, and effectively close the door to further discussions of a more sensitive or difficult nature. As well as the silences within an encounter, institutions and organisations may sustain a culture of silence around death and dying.
Of course, silence is not the panacea in all end-of-life care conversations. Some silences may be inappropriate, or the patient may find the quiet awkward and uncomfortable. We need to be able to notice the difference, to become aware of when to speak and when to remain quiet. Back et al (2009) suggest that we can identify different types of silence at play in conversations about death and dying:
- Awkward – Often without clear intention (uncertainty), but also may reflect distractedness or hostility, often masked by the clinician.
- Invitational – Wanting to give the patient a moment (or longer) to think about or feel what is happening, often after an empathic response.
- Compassionate – Recognizing a spontaneous moment (or longer) of silence that has emerged in the conversation, often when the clinician and patient share a feeling or the clinician is actively generating a sense of compassion for the patient.
They describe the use of contemplative practices such as mindfulness to ground us in present-moment awareness, that can be drawn upon during the conversation in order to clearly identify our own responses and reactions. Rather than viewing silence and words as opposites, we can begin to see silence as something which “lends integrity to speech”, Attending to both can offer an opportunity to strengthen our connections both with them, and with our inner selves.